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استطلاع الرأي إلى أي مدى تعتبر أنّ الدراسة النظريّة للطبّ في كليتنا ستخدمك سريرياً في المستقبل؟ أعتبر أنّ الفائدة معدومة في ظل النظام التدريسيّ الحالي. 28% الفائدة كبيرة جداً، وهي أساس التميز العملي. 6% الأمر نسبي، يختلف من طالب لآخر، ومن مادة لأخرى. 67% عدد الأصوات: 240 أهلاً بك ! تفضل الإبحار |
 
A glucose level that does not want to get lower
helloyellow - الجمعة, 2007-03-16 15:20 |
الوصف الكامل Background: A new patient who recently moved to your town comes to see you.
He is a pleasant 70-year-old man who is on insulin. While ordering all the usual tests (fasting Lipids, HbA1c, microalbuminurea), he shows you his glucose log. He checks his glucose several mornings each week. You notice that his morning glucose is usually about 160 mg/dl. You increase his bedtime NPH and tell him to return in few weeks. The morning glucose continues to be elevated around 160 mg/dl. You verify that he is self-administrating the insulin properly after first mixing it. The insulin is kept refrigerated and has not expired. You increase the bedtime NPH again. He returns with morning glucose levels still around 150 mg/dl. At this office visit he complains about frequent vivid nightmares and sweating, which wake him from a sound sleep. He is really motivated to get his glucose under control, and he is concerned that his morning glucose is still running high. What should you now do to improve his glycemic control?
الشكوى الرئيسية CC: القصة المرضية HPI: الأجهزة الأخرى ROS: السوابق المرضية الشخصية PMH: السوابق المرضية العائلية FMH: الوضع الصحي والاجتماعي SH: الفحص السريري Clinical Exam: التشخيص التفريقي DD: الاستقصاءات Investigations: التدبير Managment: كتابة حرة وطرح موضوع النقاش!: |
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it is somogyi effect ....
the treatment is reducing evening insulin....
frequent vivid nightmares and sweating=> hypoglycemia caused by the high dose of Insulin
This question requires you to recognize nocturnal hypoglycemia and to respond appropriately
Nocturnal hypoglycemia is a serious issue in diabetics treated with insulin.
A large drop in glucose could trigger an MI or even death if unrecognized—as the case often is because the patient is asleep.
Some clues for serious nocturnal hypoglycemia are:
vivid nightmares
waking with profuse sweating
and morning glucose that does not decrease with increasing evening insulin doses.
The reason for the morning glucose elevation is that the glucose level is indeed dropping during the night, but dropping too much.
This drop in triggers a response involving Glucagon, Cortisol, Growth Hormone, Epinephrine, and the sympathetic nervous system.
The Glucagon effect is usually minimal in type I DM because they often lose their glucagons response to hypoglycemia.
The other defenses occur at lower Glucagon levels and take longer to act.
By the time they do act, They often '' overshoot the mark '' and result in an elevated glucose, which is detected as hyperglycemia in the morning.
If this is suspected, the evening insulin must be reduced until you are sure that this is not the case.
Another protective maneuver is to ask the patient to administer their evening NPH insulin at bedtime. This often allows the peak effect of the insulin to occur after the patient is a wake.